Healthcare Provider Details

I. General information

NPI: 1770700510
Provider Name (Legal Business Name): ANIL ABRAHAM MATHEW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13055 W MCDOWELL RD
AVONDALE AZ
85392-6449
US

IV. Provider business mailing address

901 MCCLINTOCK DR STE 202
BURR RIDGE IL
60527-0872
US

V. Phone/Fax

Practice location:
  • Phone: 882-220-6432
  • Fax: 574-335-0779
Mailing address:
  • Phone: 630-655-6748
  • Fax: 574-335-0741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number238788
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number01076796A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: